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Question: From Dr Emna Trigui (Tunisia): Good morning every one and thank you for this very rewarding session. I have a few questions please: 1- for patients undergoing biphosphonate treatment for bone metastases, and who require dental care, possibly by dental extraction: what are the precautions to be taken in relation to the treatment?
Answer: From Dr Ripamonti: 1. The patient has to stop bishosponares, do the treatments and wait at least 1 month from the end of the treatment. It must be re-evaluated by the dentist before deciding whether to continue with bisphosphonates. If the patient must undergo professional scaling, he must take antibiotic therapy for at least 3 days
Question: From Dr Emna Trigui (Tunisia): 2. What is the optimal dose for corticosteroids in case of spinal cord compression/dyspnea? and when should they be stopped after spinal cord compression radiotherapy?
Answer: From Dr Ripamonti: 2. Regarding spinal cord compression, in acute setting when it is not possible to treat with RT soon, the dose of corticosteroids may arrive at 100 mg ev. The dosage is gradually reduced with the onset of RT Regarding dyspnea the dose of steroids are related to the cause. Please see ESMO open in few days the ESMO GLS on dyspnea by Hui D et al. will be published.
Question: From Dr Emna Trigui (Tunisia): 3. What is the optimal dose of morphine for treating dyspnea?
Answer: From Dr Ripamonti: 3. It depends if the patient is opioid tolerant or opioid naïve (see GLS)
Question: From Dr Emna Trigui (Tunisia): 4. For patients with impaired renal function: what is the limit of creatinine clearance to be able to prescribe morphine or second line analgesics like codeine? and if there is impaired renal function: what can be prescribed for pain?
Answer: From Dr Ripamonti: 4. Be carefull for Stage 3 - Moderate impairment; GFR 30-59 mL/min/1.73 m2 • Stage 4 - Severe impairment: GFR 15-29 mL/min/1.73 m2 Codeine is not good in presence of renal impairment because it has at least 5 active metabolites Fentanyl and methadone are safer drugs when kidneys are nor working well.
Question: From Dr Emna Trigui (Tunisia): 5. Can we combine morphine and second-line analgesics such as codeine?
Answer: From Dr Ripamonti: 5. No you cannot because codeine is a prodrug of morphine and they compete for the same receptors
Question: From Dr Emna Trigui (Tunisia): 6. In case of side effects such as hallucinations or urinary retention under morphine, What should be done?
Answer: From Dr Ripamonti: 6. Hydrate the patient and swith to another strong opioid
Question: From Dr Emna Trigui (Tunisia): 7. For patients who are vomiting or have difficulties with the oral route, can we use the patch directly or morphine by injection only?
Answer: From Dr Ripamonti: 7. In these cases you can use fentanyl patch or morphine sucute or rectally